Author's response to reviews Title: Influenza vaccination among healthcare workers in a multidisciplinary University hospital in Italy Authors: Susanna Esposito (susanna.esposito@unimi.it) Samantha Bosis (sam.tha@katamail.com) Claudio Pelucchi (pelucchi@marionegri.it) Elena Tremolati (e.tremolati@trubbiani.it) Caterina Sabatini (catesab@yahoo.it) Margherita Seminio (marghes@hotmail.it) Paola Marchisio (paola.marchisio@unimi.it) Francesco della Croce (f.dellacroce@policlinico.mi.it) Nicola Principi (nicola.principi@unimi.it) Version: 2 Date: 22 July 2008 Author's response to reviews: see over
Editor-In-Chief BMC Public Health 21 July 2008 Dear Editor, Thank you for giving us the opportunity to consider our manuscript # 1543408469191445 Influenza vaccination among healthcare workers in a multidisciplinary University hospital in Italy, adequate for publication as Original high-quality research paper in BMC Public Health. Please find attached the revised manuscript and our replies to questions and recommendations. On behalf of all coauthors, I declare that the text has been reviewed by a native English speaker with appropriate knowledge of the subject matter. We hope that you will now find the paper suitable for publication in Vaccine. Yours faithfully, Nicola Principi Institute of Pediatrics, University of Milan, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Via Commenda 9, 20122 Milano, Italy; Phone: +39-02-55032498; Fax: +39-02-50320206 E-mail: Nicola.Principi@unimi.it
Replies to Reviewer 1 (Rodrigo Jimenez Garcia) Thank you for the approval of our paper with no revision.
Replies to Reviewer 2 (Sue Skull) Thank you for your carefulness and competence. We have modified the paper according to your recommendations. 1. We have clarified that we studied the associations between all the HCWs characteristics, knowledge and attitudes and vaccination status, with all of the answers included in the final model (p. 6, lines 147-150). 2. We have clarified that influenza vaccination coverage among Italian HCWs at a large multi-disciplinary hospital is very low and that poor knowledge of influenza, its consequences and its prevention were associated with low vaccination rates (p. 13, lines 305-307). Moreover, other HCWs characteristics were associated with being unvaccinated (p. 13, lines 310-313). 3. In Tables 1-4 an additional first column giving the overall results has been added (pp. 20-23). 4. We have clarified that this is the first comprehensive study on influenza vaccination among HCWs conducted in Italy and to the best of our knowledge one of the few researches ever performed that compares the personal use of influenza vaccination in different settings of practices and in different types of HCWs. Moreover, our study sample was larger than that evaluated in previous reports and, probably because of the active involvement of our hospital s Health Management Unit, we obtained an excellent participation rate (p. 10, lines 236-242). 5. We have added that respondents in our study said that the preferred source of a future vaccination would be the hospital prevention service, followed by the ward on which the HCWs work. These findings should also be considered as a focus for future promotional activities (p. 12, lines 288-291). 6. Among the limitations of this survey, we have clarified that the questions on the HCWs knowledge of influenza vaccines and antiviral drugs could be considered a bit difficult. However, these answers only support our conclusions, did not influence our multivariate analysis and confirm the need of comprehensive educational program on influenza and its prevention among HCWs (p. 12, lines 298-302). Moreover, according to another reviewer s suggestion, we have clarified that despite there is no prior research to show that fear of avian influenza affects vaccination rate, our data demonstrate that a limited number of respondents declared a fear of avian influenza (p. 8, lines 189-194). Considering that this is a new information, although it could not be necessary to draw our conclusion, we prefer to present also this answer together with all the questions and all the answers. 7. According to your comments and the ones of another reviewer, the sentence that described the weaknesses of the previous studies has been deleted (p. 3, line 77). We have also clarified that there were no exhaustive and comprehensive data on
compliance with influenza vaccine recommendations in Italy, with different job categories as well as different specialties included in a single study (p. 4, lines 78-79 and 89-90). 8. The reference of Murray et al. has been added (p. 17, lines 410-412). 9. As suggested, Allergology has been changed in Allergy (p. 4, line 102). 10. In all the tables, no option for yes/no questions has been removed (pp. 20-23).
Replies to Reviewer 3 (Anne Cowan) Thank you for your carefulness and competence. We have modified the paper according to your recommendations. 1. As suggested, specialty has replaced specialization. 2. It has been clarified that paramedics were health aides or healthcare assistants (p. 5, lines 114-115). 3. Only the last publication by CDC has been cited (p. 3, lines 62-65; pp. 15-16, lines 370-373). 4. A reference from World Health Organization on influenza recommendations has been added (p. 3, line 72; p. 16, lines 374-376). 5. Also in this case, references on recommendations from World Health Organization have been included (p. 3, line 72; p. 16, lines 374-376). 6. The sentence that described the weaknesses of the previous studies has been deleted (p. 3, line 77). 7. We have clarified that there were no exhaustive and comprehensive data on compliance with influenza vaccine recommendations in Italy, with different job categories as well as different specialties included in a single study (p. 4, lines 78-79). We have also added that our previous study published in Vaccine was focused mainly on understanding weather obstetricians/gynecologists, neonatologists and pediatricians were convinced that influenza was a relevant problem to their patients and actively promoted influenza vaccination. No information on job categories as well as specialties different from HCWs caring for women and children were available (p. 4, lines 86-90). 8. The high response rate in our study could be explained by the fact that the Health Management Unit of our hospital was actively involved in the study (p. 10, lines 240-242). 9. It has been clarified that the anonymous questionnaire was different from the one used in our previous study and was developed iteratively by experts in general medicine, surgery, emergency and preventive medicine (p. 6, lines 128-132). It has also been added that it consisted of five items and 18 questions (p. 6, lines 132-133). 10. We have clarified that despite there is no prior research to show that fear of avian influenza affects vaccination rate, our data demonstrate that a limited number of respondents declared a fear of avian influenza. Considering that this is a new information, although it could not be necessary to draw our conclusion, we prefer to present this answer together with all the questions and all the answers (p. 8, lines 189-194). 11. We have clarified that considering that all of the high-risk categories listed in Table 3 are included in the Italian recommendations, if everyone
got it right, response rate would be 100% for each category (p. 8, lines 196-198). We have also added that there was no other category included on the survey that was not listed in Table 3 (p. 9, lines 205-206). 12. Among the limitations of this survey, we have clarified that the questions on the HCWs knowledge of influenza vaccines and antiviral drugs could be considered a bit difficult. However, these answers only support our conclusions, did not influence our multivariate analysis and confirm the need of comprehensive educational program on influenza and its prevention among HCWs (p. 12, lines 298-302). 13. We have clarified that awareness of high-risk categories was coded as awareness of all of the high-risk categories for which influenza vaccination is strongly recommended (p. 9, lines 219-220; p. 24, Table 5). Moreover, you are right (sorry for the distraction) and the p-value for Emergency Department has been corrected (p. 24, Table 5). 14. We have clarified that respondents in our study said that the preferred source of a future vaccination would be the hospital prevention service, followed by the ward on which the HCWs work. These findings should also be considered as a focus for future promotional activities (p. 12, lines 288-291). 15. Limitations of the study are described, according to your request (p. 12, lines 292-302). 16. Also considering the comments of another reviewer, we have clarified that Emergency Department is the area to which patients at highest risk of influenza complications are admitted and in which HCWs have the greatest risk of exposure to influenza from patients (p. 10, lines 228-231). On the other hand, in our Emergency Department a large number of attendees is represented by patients with chronic underlying disorders who attended the area because of acute problems. 17. According to your suggestion, non-compliance replaces global disagreement (p. 10, line 232). 18. As suggested, the phrase at a large multi-disciplinary hospital has been added (p. 13, lines 305-306). 19. We have clarified that poor knowledge of influenza, its consequences and its prevention were associated with low vaccination rates (p. 13, lines 306-307). 20. The word complications is now plural (p. 3, line 75). 21. The terms Allergy and Pneumatology replace Allergology and Pneumology, respectively (p. 4, line 102; p. 5, line 104). 22. The space required has been added (p. 6, line 135). 23. The main reason for not getting vaccinated is discussed in a new sentence (p. 7, lines 173-174). 24. Such as replaces such as for example (p. 10, line 249). 25. R in Ors has been capitalized (p. 13, line 321).
Replies to Reviewer 4 (Lyn Finelli) Thank you for your comments. We have modified the paper according to your recommendations. 1. Editing for English-language conventional expressions has been performed, according to your suggestion. 2. We have clarified that no differences in the reasons for getting vaccinated or not were observed according to job category. Moreover, the different wards in each Department showed similar results (p. 7, lines 175-176). Regarding the HCWs opinions concerning the severity and epidemiology of influenza, the knowledge of Italian Ministry of Health recommendations concerning influenza prevention as well as the knowledge of influenza vaccines and antiviral drugs, again results were similar comparing different job categories as well comparing the different wards in each Department (p. 8, lines 192-194; p. 9, lines 206-207 and 213-219). 3. Only the recommendations on prevention and control of influenza published in 2007 have been included among the references (p. 3, lines 62-65; pp. 15-16, lines 370-377). 4. The number of references has been reduced from 17 to 7 (p. 3, line 74; pp. 17-18, lines 406-432). 5. The sentence on the reluctance of HCWs to accept influenza vaccination has been modified according to your suggestion (p. 3, lines 74-75). 6. According to your recommendation, underlined has been replaced by demonstrated (p. 4, lines 84-85). 7. Opthalmologic Surgery and Transplant Surgery have been used in place of Eye Surgery and Transplantation Surgery, respectively (p. 5, lines 105-106). 8. The word employees has been added as requested (p. 5, line 115). 9. The word educational has been added as requested (p. 5, line 119). 10. We have clarified that all of the participants had to complete a self administered standardized questionnaire at pre-arranged times (p. 5, lines 124-126). 11. Change of shift replaces handover, as suggested (p. 5, line 127). 12. We have clarified that participants had a self administered questionnaire (p. 5, line 125). 13. The sentence on statistical analysis has been modified according to your suggestion (p. 6, lines 143-145). 14. We have clarified that the questionnaires were fully completed by 2,143/2,240 (95.7%) HCWs (p. 7, line 154). 15. The expression getting vaccinated has been used in place of undergoing vaccination (p. 7, lines 166 and 173).
16. We have added that results were similar regardless of job category and ward in each Department (p. 7, lines 175-176; p. 8, lines 192-194; p. 9, lines 206-207 and 213-219). At this regards, despite the Department of Medicine had the highest number of physicians and physicians were more vaccinated that nurses and paramedics, the vaccination rates were not the highest. 17. As recommended, severity has been used in place of seriousness (p. 8, line 183). 18. According to your recommendation, we have clarified that the Emergency Department is the area to which patients at highest risk of influenza complications are admitted and in which HCWs have the greatest risk of exposure to influenza from patients (p. 10, lines 228-231). 19. As recommended, worse has been used in place of least (p. 10, line 232). 20. As suggested, support the findings of has been used in place of substantially agree with those (p. 10, line 243). 21. As suggested, the word complications has been used in place of problems (p. 10, line 252). 22. As you suggested, lack of knowledge has been used in place of very high number of wrong answers to the questions (p. 10, lines 251). 23. We clarified that our findings mean that we need not only to remove barriers but to provide information about what the current recommendations are and what they mean (p. 11, lines 254-255).